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HEMOSTASIS

By Prof\ Sameh Shamaa Prof Of medical Oncology and Internal medicine Mansoura Faculty Of Medicine HEMOSTASIS

HEMOSTASIS
Def:- stoppage of bleeding from the blood vessels Mechanisms (I) v.c of blood vessels (II) platelet plug formation (III) Blood coagulation (fibrinogen fibrin) (IV) Clot retraction (V) fibrinolysis to dissolve the clot
HEMOSTASIS

PRIMARY HEMOSTASIS
includes the processes that result in the .formation of the platelet plug -:Necessary factors
The blood vessels : the vessel walls esp. the .subendothelial layer The platelets: plasma glycoproteins 2fibrinogen Willebrand factor ,which also presents inside the platelets

:Mechanisms
.v.c of the bl. vessel-1 Platelets adhesion to subendothelial layer, ( Willebrand- 2 )factor is necessary for this stage :adhesion of platelets- 3- platelets secretion their activation and secretion of ADP,adrenaline, noradrenaline > aggregation & activation of .other platelets .Aggregation of platelets- 4 .Formation of capillary plug- 5

HEMOSTASIS

Exploration of the 1ry homeostasis

1) Important points in the history of any bleeding patients :

HEMOSTASIS

Family history Duration (recent onset or since childhood) Duration of the bleeding episode. Circumstance of bleeding (spontaneous, after trauma, or surgery)

HEMOSTASIS

:Type and character of bleeding - Purpuric spots


(capillary or platelets defect not characteristic of hemophilia) - Hematoma, hemarthrosis or large ecchymoses at the site of trauma : suggests hemophilia (coagulation defect) - Sudden severe bleeding from multiple sites after prolonged surgery or during obstetric procedures suggests acquired fibrinogen defect

HEMOSTASIS

2) Investigations :

HEMOSTASIS

1) Capillary resistance test of Hess 2) Platelets count 3) Bleeding time time needed for the platelet plug formation If . N. ------ Normal 1ry homeostasis . ------ platelet or vascular defect.

HEMOSTASIS

Capillary resistance test of : Hess


sphygmomanometer cuff above the cubital fossa and raise the pressure to 100 mm Hg (or midway between systolic & diastolic if systolic pressure <100) for 5 - 7' minutes- deflation '3 minutes later count the number of petichea in area of 3 cm diameter, 1 cm below the cubital fossa Normally up 10 if more than 20, means platelets or capillary wall defect
HEMOSTASIS

4) Other tests only done if there is a prolonged bleeding time with normal platelet count - Measurement of capillary resistance - Measurement of Willebrand factor - Platelets function tests (Adhesiveness, Aggregation) - other tests for platelets (clot retraction, prothrombin consumption).
HEMOSTASIS

Coagulation of Blood
Def :- represent the conversion of fibrinogen (soluble protein) to fibrin (insoluble) meshwork which occludes the point or vessel rupture.

HEMOSTASIS

First Step :Activation of factor X


BY One of 2 systems: I-urgent system (Extrinsic system.) II-delayed system (Intrinsic system.)

HEMOSTASIS

systems of coagulation
I-urgent system. Extrinsic system. 12-20'' (seconds) In vivo only. Due to tissue damage. II-delayed system Intrinsic system. 4-8' (minutes) In vivo & in vitro due to contact with foreign surface

Tissue factor activation of contact system X < ------------------------------------IX a < ---------------- IX Xa 2- prothrombin thrombin 3-fibrinogen Fibrin

HEMOSTASIS

EXTRINSIC SYSTEM
FACTORS NICESSORY ARE: Factor X Tissue factor and Factor VII Tissue F. VIIa Xa X VII

Blood vessel HEMOSTASIS

INTRINSIC SYSTEM
Necessary factors: XII (Hageman factor) - Contact system XI Kallikrene kininogene - F. IX - F. VIII - F. X - Ca. ++ - phospholipids of the platelets membrane HEMOSTASIS

Contact System: Foreign surface |--------------------------------------------------| Kalierne XII kininogene Fragmentation XIIa XI XIa

Rest of intrinsic pathway HEMOSTASIS IX

Rest of intrinsic pathway IX Platelets Ca ++ IXa X VIIIa VIII Xa II IIa

HEMOSTASIS

Second Step: of Coagulation


Thrombin Formation: (IIa) Factors needed: - prothrombin (II) Ca++ - Xa II - V (acceleririe) - phospholipids - Ca + + IIa
HEMOSTASIS

platelets V Xa
Ca++

3 Step :Fibrin Formation


rd

Fibrin Formation:-----------------------IIa XIII (Fibrinogen) -------------------Ia (Soluble fibrin) XIIIa

HEMOSTASIS

Insoluble Fibrin

Physiological anticoagulants
1- Serine protease inhibitors :inhibit the coagulation cascade. 2-Neutralizers of activated coagulation factors (components of protein C system)

HEMOSTASIS

1-Serine protease inhibitors:


1-Antithrombin (III). 2-Heparin and heparin like substance. 3-Alpha 1 antitypsin. 4-Alpha 2 macroglobulin
HEMOSTASIS

1-Protein C: synthesized in the liver, vit. K dependant, activated by thrombin. 2-Thrombomodulin. 3-Protein S and C4b-binding protein. HEMOSTASIS

Neutralizers of activated-2 coagulation factors : (components of protein C )system

Fibrinolysis
is the process wherein a fibrin clot, the product of coagulation, is broken down.Its main enzyme plasmin cuts the fibrin mesh at various places, leading to the production of circulating fragments that are cleared by other proteases or by the kidney and liver

HEMOSTASIS

HEMOSTASIS

Measurement
When plasmin breaks down fibrin, a number of soluble parts are produced. These are called fibrin degradation products (FDPs). FDPs compete with thrombin, and so slow down the conversion of fibrinogen to fibrin (and thus slows down clot
).formation

Exploration of the coagulation


(I) whole blood clotting time Normally 4-10 minutes Generally ---> N. in platelets defects. = coagulation defect But not very sensitive: - only +ve when blood coagulation is very defective
HEMOSTA fibrinolysis HEMOSTASIS

(2) One stage prothrombin time: general exploration or the extrinsic pathway (Quick time) .N : 16-18 sec +addition of tissue thromboplastin ca++ to decalcified plasma ---> measure .the time till coagulation occur Affected by factors VII, X, V, II & )fiboinogen (only severe defect
HEMOSTASIS

(3) partial thromboplastin time (PTT) or CKT(cephaline koalin time) General exploration of the intrinsic pathway clotting time of recalcified plasma in the presence of phospholipid (cephaline), while koalin powder for activation of Hageman factor'. Affected by factors XII, XI, IX, VIII, X, II
HEMOSTASIS

(4) Thrombin time detect the defects in the conversion of fibrinogen ---> fibrin Measured by addition of thrombin to citrated patients plasma
If polonged Abnormalities of fibornogen (hypo or hyper or dysfibrinogenemia) Heparin Presence of some abnormal proteinswhich inhibits the polymerisation of monomers of fibrin. (e.g myeloma protein

HEMOSTASIS

(5) Deficiency of F XIII (fibrin stabilizing factor ) detected by noting the solubility of fibrin
in 5M urea or 1% monochloroacetic acid (can't dissolve fibrin in the presence of factor XIII).In congenital defect of f. XIII ---> dissolution of the clot in <10.

(6) Assay for each cogulation factor is available


HEMOSTASIS

(7) Detection of coagulation inhibitors: 1-Inhibitors for a specific factor (especially F. VIII) usually ---> severe hemorrhage 2-Inhibitors against platelets or tissue phospholipids ---> prolongation of tests of coagulation (Quick or CKT) e.g L.E but usually no hemorrhagic manifestations 3- if there is of Quick test or CKT or thrombine:50% of normal plasma + 50% of patient plasma (incubation at 370c for I hour) repeat the test If become normal ---> factor defect if no correction ---> presence of inhibitors. HEMOSTASIS

PRACTICAL INVESTIGATION OF HEMOSTATIC TROUBLE


B.T Platelets count Quick test CKT Thrombin time Dosage of fibrinogen
HEMOSTASIS

PRACTICAL INVESTIGATION OF HEMOSTATIC TROUBLE


I- B.T, platelets ( 80.000; mm3) Thrombocytopenia 2- B.T, platelets normal Qualitative platelets abnormalities congenital or acquired platelet factor tests Willebrand disease

dosage of factor VIII

HEMOSTASIS

PRACTICAL INVESTIGATION OF HEMOSTATIC TROUBLE


3- Quick + CKT Other tests are N Acquired defect of several factors (II, VII, X,V) defect of factor common for 2 pathways ex. X or V or II

4- Quick N., CKT: either: I- Hemophilia Aor B. 2- Rarely ---> defect of one factor of the contact system (XII, or XI or others)

HEMOSTASIS

PRACTICAL INVESTIGATION OF HEMOSTATIC TROUBLE


5- Quick , CKT N isolated defect of factor VII

in 3, 4..5 dosage of the factors with suspected deficiency, also search for inhibitors. Ex: - Quick, normal dosage of factors---> hyperfibriongenemia which inhibit the test - Quick +CKT + no F. defect --->? Inhibitors, e.g. antiphospholipides.

HEMOSTASIS

PRACTICAL INVESTIGATION OF HEMOSTATIC TROUBLE


6-T.T either: * heparine in the blood or in the tube. Here T.T can be corrected by adding either a-toluidine blue b-Reptilase time (incomplete thrombin not sensitive to heparin and not inhibited by antithrombin III). * If (a-b also defective) ---> troubles of fibrin polymerisation :either due to abnormal fibrin (dysfibrinogenimia) or inhibition e.g by ---> myeloma protein or F.D.P. HEMOSTASIS

PRACTICAL INVESTIGATION OF HEMOSTATIC TROUBLE


7- fibrinogen * congenital afibrinogenimia or hypofibrinogenimia Acquired hypofibrinogenimia e.g.liver cirrhosis. consumption of fibrinogen: e.g. D.I.V.C, fibrinolysis

HEMOSTASIS

PRACTICAL INVESTIGATION OF HEMOSTATIC TROUBLE


8-All tests ate Normal: * Capillary fragility (usually only ecchymoses ) ---> measurement of cap.fragility. * deficient factor XIII * no hemostatic troubles.
HEMOSTASIS

Thank You
HEMOSTASIS